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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT G, <br /> -------- - - ---------------• Permit No. <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> ___ - ----------------_-_----------------" <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described- This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC -- -- -- --- ----- „ - - CENSUS TRAC n <br /> Owner's Name - --- --------- -------------------------- one <br /> -------- ---------------------Address -------- � --- CitY ------ -------- <br /> Contractor's Name ------ �--- -- --------- --------- ' '-License # ------� <br /> -- --3_ `Phone ------------------------------ <br /> Installation will serve: Residence ®Apartment House❑ Commercial []Trailer Court ;❑ <br /> Motel ❑ Other ------ ------------------------------------ <br /> Number of living units:-------L_.__ Number of bedrooms 3---"__Garbage Grinder Lot Size ------- --.----------- <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private ❑. <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam © Clay Loam 2r <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[9;1-, Sizev-7-___�_�1____t a----------------.-- Liquid Depth _-_y_________.___------ Q <br /> Capacity -U-0,'o----- Type _ Material �- No. Compartments --"_" `�..______ <br /> 0 <br /> Distance to nearest. Well ________� O_�_______________Foundation _.SCJ_!_________ Prop. Line "�_ ------_____-- <br /> LEACHING LINE [ No. of Lines ------------------- Length of each line-----IqO------- ------ Total Length ---.2--r'_p_____________ <br /> �, sr <br /> 'D' Box ___t. Type Filter Material --__� -_-""""Depth Filter Material ----l�_ _____.--------________-------- <br /> .. <br /> Distance tarest: Well _____ _Q-f------- Foundation -----t_ ------_------- Property Line ---------___ _______ <br /> F � <br /> PIT [<*" Depth I.�.__-_-___ Z ter _ Q"---- Number -------I---_____.____ Rock Filled Yes 2�- No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size ----------------------•--------- <br /> Distance to nearest: Well --------------------------------_-------Foundation -------------------- Prop. Line _._"_-_____-________-. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------------------------------------------------------------------------------------------------ -------------------------------- <br /> Disposal Field (Specify Requirements) ---------- -------------------------------------------------------------------------------------------------------------------------- <br /> --------- -------------------------------------------------------------------------------------- ------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Sar► Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become su t to Workman's Compensation laws of California." <br /> Signed ---------- -------- N---------------- <br /> 1 �4 Owner <br /> - ----------------------- ----------------- <br /> BY = " Title .1.�s 'u^------------- ----------- ------------ <br /> fother than owner] <br /> - <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY w ------------------------------------------------------------ DATEc "-€a. 0- <br /> ------------------------------------------------------------ <br /> BUILDINGPERMIT ISSUED ----- ---------------------------------------------------------------------- -----------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------- ----------------------------------------------------------------------- ------=--------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- ------------ <br /> ----------------------------------- ----------------- --- ----------------- - <br /> -----=------- <br /> Final Inspection by: --- - ---------------------------------------------------------------------Date .~- <br /> MN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />